In This Issue - Georgia Regents University

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Welcome
In This Issue
Dear Colleague,
Welcome to the first letter of the New Year from the Heart and Cardiovascular Service Line.
The Medical College of Georgia has a 50-year tradition of taking care of children with heart
problems.Therefore, it should not come as a surprise to anyone that these children, now
productive young adults, look to us for continuity of their care.The cardiovascular service
line has a highly specialized team consisting of a dedicated cadre of physicians, nurses,
perfusionists and a parents' group to take care of these complex patients. Sheldon Litwin,
M.D., Professor and Chief of Cardiology at Georgia Regents University, has special expertise
and interest in the subject and has written an overview in this edition of the newsletter. I
know you will find it interesting and informative.
Mary Arthur, M.D., Associate Professor of Anesthesiology, shares with us the benefits
of using bloodless medicine as an alternative to donor blood. Almost every week, we
discover new complications and side effects of blood t ransfusions. As such, it behooves
us to use all possible means to minimize use of blood and blood products w ithout
comprom ising patient outcomes. I am pleased to report that, owing to our evidenced
based guidelines and a team of driven individuals, blood utilization rates in our cardiac
surgery patients are one of the lowest in the country.
As we encounter an increasing number of aged patients w ith concomitant advanced
diseases, we find ourselves performing staged procedures to allow the se patients time
to recover from their multiple problems. Paul Poommipanit, M.D. writes about one such
temporizing measure, balloon aortic valvulop lasty, in patients with severe aortic stenosis
too ill t·o undergo definitive surgery. A close coordination between various specialists is
essential for optima l outcomes.
As always, we are proud of our fellows in training and some of their activities are outlined
inside. I am sure you will agree that they are all multifaceted and talented individuals wit h
considerable promise.
We have a busy year of CME activities ahead of us (schedule attached). If you have
suggestions for new topics or a different format please let us know.
Wishing you and yours the best for the New Year,
M . Vinayak Kamath, M.D.
Director, Heart and Cardiovascular Services and
Chief, Cardiothoracic Surgery
•
Welcome
•
Balloon Aortic
Valvuloplasty
• Bloodless Medicine
• Adult Congenital Heart
Disease
• Fellowship Highlights
• Conferences
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M . Vinayak Kamath, M.D.
Director, Heart and
Cardiovascular Services and
Chief, Cardiothoracic Surgery
Georgia Regents University
1120 15th Street BA-4300
Augusta, GA 30912
706-721-3226
[email protected]
G H ealth
GEORGIA REGENTS
HEART & CARDIOVASCULAR SERVICES
Assistant Professor of
For patients w ith severe aortic stenosis, th e option of
a less-invas ive procedure is becoming more common at
Georgia Regents Medical Center's Heart and Cardiovascular
Center.Subsequently, we learned that restenosis within six
months is common. Today, balloon aortic valv uloplasty is
increasingly used as a"bridge" to more definitive therapy.
Balloon aortic valvu lop lasty (BAV) increases the aortic
valve area by inflating a balloon w ithin a severely stenot ic
aortic valve. Historically, this procedure was done in hopes
of providing a durable, less-invas ive solution for aortic
stenosis.
With the advent of TAVR,BAVis being
performed more frequently.
Since surgical aortic valve replacement (AVR) provides
a durable, long-last ing solut ion for aortic stenos is, BAV
has infrequently been performed. But, with the advent
of transcatheter aortic valve replacem ent (TAVR), in
w hich an aortic valve can be implant ed percutaneously,
BAV is being performed more freque ntly, providing an
alternat ive treatm ent for seve re aortic stenos is. At the
Georgia Regents Medical Hea rt and Cardiovascular Center,
an 84'-year-old man with end-stage renal disease recent ly
underwent BAV. This patient has cardiomyopat hy with
an ejection fraction of 30 percent and moderate aort ic
stenosis. He presented with a non-ST elevation myocardial
infarction, class IV heart failu re and hypotens ion. A ca rdiac
catheterization revea led s ignif icant coronary artery
d isease of the right coronary a rtery and left anterior
descending artery. Surgery was deemed too risky since
his EF was now 20-25 percent with severe aortic stenosis
and severe mitral and tricuspid regurgitation.
The pat ient underwent high-risk stenting of his RCAand
LAD and th e previously placed intra-aortic balloon pump
was removed t he fo llow ing day. Weeks later, the patient
improved, but was still having class III-IV heart failure
and receiving daily hemodialysis wh ile havirig episodes
of hypot ension. This patient was too decondition ed to
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tolerate open-heart surgery and the decision was made
to perform BAVas a bridge to futu re AVR orTAVR.
The patient was brought to the cardiac catheter ization
lab, gracio usly provided by the pediatr ic ca rdiovascular
service. Cardiac anesthesia and hemodynamic support
were provided. Transesoph ageal echocard iography
demonstrated a valve area of 0.8-0.9cm2 (severe aortic
stenos is). One balloon inflatio n was do ne and repeat
echocardiography demonstrated a valve area of 1.2cm2
(moderate aortic stenosis).The patient then had a SO percent
decrease in the pressure gradient across the valve. Given
his ot her crit ical illnesses, th e team decided to term inate
the procedure. The patient has slow ly recovered and is
wor king with physical therapy to improve his conditioning.
BAV for severe aortic stenosis is used to temporize prior
to surgica l AVR, assess for response and as an alternative in
severely symptomatic patients who are not candidates for
other procedures such as AVR orTAVR. A multidisciplinary
approac h at Georgia Regents University involving cardiac
a nesthes iolog ist s, cardiac surgeons, interventiona I
cardiolog ist s and cardiovasc u lar imaging specia lists
im proved the patient 's quality of life.
Mary E.Arthur, M.D.
Associate Professor,
Anesthesiology and
Perioperative Medicine
Blood Enhances Oxygen
Why do we care?
Blood enhances oxygen-carrying capacity, improves
wound-clotting and provides volume support for cardiac
output. Nevertheless, more and more patients are seeking
safe and effective alternatives to blood transfusions during
surgery- even cardiac s urger y- because of religious
convictions, medical concerns or personal preference.
Religious objections tend to be limited to primary
components (packed red blood cells, platelets and fresh
frozen plasma) while secondary compo nents such as
albumin and factor concentrates are generally acceptable.
Physicians are increasingly accommodating patients'
preferences for bloodless surgery because of mounting
evidence that blood transfusions portend worse outcomes.
Minimizing bleeding and limiting blood transfusions have
become important elements of quality improvement
programs. Bloodless cardiac surgical procedures require
special expertise, precise monitoring, state-of-the-art
equipment and innovative techniques.
The GRU Bloodless Medicine and Surgery Program was
designed expressly for these reasons.
Concerns regarding the safety and efficacy of allogeneic
blood transfusion s, the impact on patient outcomes and
the astounding costs and challenges associated with
maintaining an adequate supply of blood products has
renewed an interest in alternatives to transfusion. In
addition to transfusion-related risks such as infections
respiratory failure and thromboembolic complications,
red blood cell transfusions may alter immune function,
impacting long-t erm survival.
I
What do we know?
Most cardiopulmonary bypass patients have sufficient
wound-clotting after reversal of heparin and do not require
transfusion . Evidence suggests that transfusions might not
improve the outcomes of stable non-bleeding patients in
nearly 90 percent of the common transfusion scenarios
reviewed. Transfusions are only deemed appropriate for
patients 65 and older with comorbidities and a hemoglobin
of <8 g/dl.
Several tools are available to accommodate the need or
preference for bloodless surgery, covering all phases of the
procedure: preoperative, intraoperative and postoperative.
How big is the problem?
Almost 15 million units of packed red blood cells are
transfused annually in the United States during surgery,
with cardiac operations consuming as much as 15 percent
of the nation's blood supply. This percentage is growing,
largely because of the increasing complexity of cardiac
surgical procedures.
1)Patient's
bloodcollected
2) Bloodvolumerestored
usingplasmaexpanders
(Albumin,Hetastarch or
Crystallods).
ANHAcute Normovolemic Hemodilution
3) OffCPB,thepatient's
bloodisreturned,
connedionmaintains
closedcircut.
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Oneimportant strategy isacute
normovolemichemodilution, aprocess
increasingthevolumeofthe patient's
ownstoredblood using expanderssuchas
albumin,hetastarch andcrystalloids.The
tubing remains connectedtothe patientat
alltimes, maintaining aclosed circuit.The
patient's stored blood, whichhasallthe
majorclottingfactorsaswellasplatelets, is
returnedtothepatient after weaningfrom
cardiopulmonary bypass.
How do we involve the patient?
Before surgery, a member of the blood conservation team
gives t he pat ient a form listing all the factor concentrates.
The patient t hen decides which concentrates can be used
during the procedure.
Our multidisc ip linary blood management team
works toget her to limit blood transfus ions and decrease
per ioperat ive bleeding while sti ll mainta inin g safe
outcomes. At GRU, about 25 inpatient and outpatient
cases per month utilize bloodless medicine tec hniques
across all specia lty areas. Four successful bloodless cardiac
surgery procedures have been done in th e last few months.
More t han 180 comm unity members att ended a
Bloodless Medicine and Surgery Program seminar last fall
highlight ing techniques t hat enable medical and surgical
treatment w it hout blood tra nsfusions, attesting to the
acute interest and growing awareness ofthis burgeoning
field of medicine. GRUis happy to fil l t his vital niche in t he
community.
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Cardiovascu lar disease is the leading cause of death
wor ldw ide. In addition to acquired diseases associated
wit h aging, heart disease can be present from birth.
Because of steady advances in medicine, most pat ients
with congenital heart disease today survive into adulthood
and many have normallifespa ns. Patients with congenital
heart problems are likely to benefit from consultat ion or
ongoing care from a cardiovascu lar clinician or team with
special interest or training in th is area.
Themost common congenital heart
condition is the bicuspid aortic valve.
A
The most common congenital heart condit ion is the
bicuspid aortic valve. About 1 in 100 people have a bicuspid
aortic valve. The aortic va lve normally has three distinct
leaflets (Figure 1A). Each leaflet, or cusp, is associated wit h
a s inus of Va lsalva (Figure 1C) in t he aort ic root.The right
and left coronary arteries arise from the respective right
and left sinuses ofValsalva.The noncoronary sinus does
not give rise to a coronary artery. The three leaflet s of the
aort ic valve open to produce a t riangle-shaped orifice
(Figure 1A) and whe n closed, appear like a "Mercedes"
sign (Figure 1B).Patients w it h bicuspid aort ic valves have
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c
B
D
B
A
only two leaflets (Figure 2A valve open, Figure 28 valve
closed). In some cases, this results from fusion of the
commissure between two leaflets producing a raphe
(Figure 28).
In normal individuals, the cellophane-t hin valve
leaflets perform admirably over the course of 80-plus
years. However, bicuspid va lves produce turbulent
flow patterns that likely contr ibute to early damage
of the leaflets. Degenerative changes of the leaflets,
including prolapse or calcification (Figure 20), may cause
regurgitation or leakage (Figure 2E) or stenosis (Figure
2A). These conditions typically do not become evident
until adulthood. Echoca rdiogra phy is generally performed
on adult patients with bicuspid valves every one to two
years to look for regurgitation or stenosis. Once these
abnormalities become clinically significant, surgical valve
replacement is usually recommended (Figure 3C).
c
D
Bicuspid aortic valveis also linked to
abnormalities of the aorta.
Bicuspid aortic valve also is also linked to abnormalities
of the aorta. Coarctation of the aorta, a narrowing of the
descending thoracic aorta just after the take-off of the left
subclavian artery (Figure 3D) occurs in up to 40 percent
of patients with bicuspid valves. Such narrowings have
a number of adverse effects, particularly hypertension
of the upper body. In addition to aortic coarctation, the
wall of the entire aorta may be abnormal. This may lead
to enlargement and/ or dissection of the ascending aorta.
For this reason, aortic imaging with MRI or CT is often
done periodically in patients with bicuspid valves (Figure
3A ang B).The natural history of patients w ith bicuspid
valves and aortic enlargement is similar to that of patients
with Marfan's syndrome. Aortic root replacement may be
recommended at the time of valve replacement surgery
in those w ith bicuspid valves, or sometimes even before
the valve itself requires surgica l intervention. Angiotens in
receptor blocking agents are increasingly being used to
protect the aorta from expansion in patients with various
aortopathies, including those with bicuspid aortic valves.
Being born with 2 rather than 3 leaflets of the aortic
va lve req uire s lifelong monitoring . To effectively
diagnose and treat the significant valvular and vascular
complications that can arise in patients with bicuspid
aortic valve, referral to centers w ith specia lized interest
in medical care, imaging and surg ical therapy for patients
with adult congenital heart disease is appropriate.
A
B
Figure3.Aand B.Twoviewsofaorticrootaneurysm (arrowwith
dissection ofdescending aorta (arrowheads). C.CTimageof
mechanical aorticvalveinopenposition. D.Imageofrepaired aortic
coarctation withnativeaorta(arrow)andgraftgoingaroundcoarct
(arrowhead).
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AminYehya, M.D.
3rdYear
Adult Cardiology Fellow
Alberto Morales-Pabon, M.D.
3rdYearChief
Adult Cardiology Fellow
FethiBenraouane, M.D.
3rdYear
Adult Cardiology Fellow
Justin MackenzieVining, M.D.
2ndYear
Pediatric Cardiology Fellow
Michele Murphy, M.D.
1stYear
Adult Cardiology Fellow
lauren Holliday, M.D.
1stYear
Adult Cardiology Fellow
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JoseCuellar, M.D.
3rdYear
Adult CardiologyFellow
SyedS.Zaidi, M.D.
2ndYear
Adult Cardiology Fellow
RodEvanPellenberg, M.D.
2ndYear
Pediatric Cardiology Fellow
Adu lt Cardiology Fellowship Highlights
Pediatric Cardiology Fellowship Highlights
November2012
August 2012
·RodEvanPellenberg, M.D.,submittedthe manuscript,
"Papilary FibroelastomaofTricuspid ValveinaPediatric Patient"andwas
acceptedto Annals ofThoracic Surgery.
·AminYehya,M.D.,waselectedPresidentofthe
HousestaffOrganization for2012-13.
·RodEvanPellenberg, M.D.,lecturedforfirst-yearmedicalstudents'
embryologycourse.
October 2012
·JustinMackenzieVining,M.D., wasselectedaGRUFellow
Representative Nonvoting memberoftheGeorgia ChapteroftheACC.
December2012
·JustinMackenzie Vining,M.D.,was boardcertifiedingeneral pediatrics by
theAmericanAcademyofPediatrics.
201.3 Pediatric Fellowship Program Match
ThePediatric Fellowship Program is happytoannouncethematchfora
newfellowwhowill startJuly 1,2013.
StefaniM.Samples,M.D.- MedicalCollegeofGeorgiaatGRU.
2013 Adult Fellowship Program Match
• Amin Yehya, M.D.,Alberto Morales-Pabon, M.D.and Fethi Benraouane,
M.D. passedtheEchocardiography Boardson their first attempt in July. This
100 percent passrate for our fellows wasalso associatedwith somefellows
scoring inthe901hpercentile.
·The 12 adult cardiology fellows completed their first nationwide
American College of Cardiology In-Service Exam. Overall program score
was significant ly above thenational average. Thefinal year trainees scored
100 points above the national average for all other third year cardiology
fellowship traineesnationally.
November 2012
·FourofourcardiologyfellowspresentedtheirresearchpostersattheAnnual
Georgia Chapterof theAmericanCollegeofCardiology.
·LaurenHolliday,M.D.wasselectedto betheFellowRepresentative Nonvoting
memberoftheGeorgia ChapteroftheACC.
:"':oo!•
TheCVDiseaseFellowship Programhadahighlysuccessful matchfornew
fellows whowill startJuly 1,2013.
-· · Amin Yehya, M.D., organized the
collection of toysfortheJamesBrownToy
Drive for local needy children at the
James Brown Arena on December 20.
Rebecca Napier,M.D. - GRUResidency Program
Pratik Choksy,M.D., M.B.B.S.- GRUResidency Program
AmudhanJyothidasan, M.D.- University of Massachusetts
LorenMorgan,M.D.- UniversityofSouthCarolina
report.gru.edu/archives/13424
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'I
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,, -CME
-- Le Ctures
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Please contact us for more information
. . .
106-72 -2136 ' .
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February 22
Speaker: Michael Luc, M.D., 2nd Year
GRU Cardiology Fellow
Topic: "StressTesting"
March8
Speaker: Simi Kumar, M.D., 1stYear
GRUCardiology Fellow
Topic: "Cardiac CT/Cardiac MRI"
March 15
Speaker: Ashkan Attaran, M.D., /nd Year
GRU Cardiology Fellow
Topic: "Chronic Heart Failure"
March22
Speaker: Lauren Holliday, M.D., 1st Year
GRU Cardiology Fellow
Topic: "Intra-aortic Balloon Pumps"
March 29
May3
Speaker: Alberto Morales, M.D., 3rd Year
GRU Cardiology Fellow
Speaker: Vincent Robinson, M.D.,
Program Director,CV Disease
Topic: "Diastolic Heart Failure"
Topic: "The New ACGME"
April12
May24
Speaker: Michele Murphy, M.D., 1stYear
GRUCardiology Fellow
Speaker: Fet hi Benraouane, M.D., 3rd Year
GRU Cardiology Fellow
Topic: "Women and Heart Disease"
Topic: "Recanalization of Chronically Occluded
Graft: Is it a Paradigm Shift?
April19
Speaker: Reza Amini, M.D., 2nd Year,
GRUCardiology Fellow
Topic: "Novel Anticoagulation Therapy"
April26
Speaker: Jose Cuellar, M.D., 3rd Year
GRU Cardiology Fellow
Topic: "Comprehensive Approach to Syncope"
Cardiovascular Conferences
Please contact us for more information
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706-721-2736
Cardiovascular Update for Primary CareProviders
GRUCoronary Revascularization Symposium
October 26-27, 2013 ·
Marriott Riverfront
Augusta, GA
June 6-9, 2013
Kiawah Island, SC
GRUCardiac Conference
October 9-13, 2013
Chateau Elan
Braselton, GA
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